COVID-19 epidemiology and changes in health service utilization in Azraq and Zaatari refugee camps in Jordan: A retrospective cohort study

Abstract

Background The effects of the Coronavirus Disease 2019 (COVID-19) pandemic in humanitarian contexts are not well understood. Specific vulnerabilities in such settings raised concerns about the ability to respond and maintain essential health services. This study describes the epidemiology of COVID-19 in Azraq and Zaatari refugee camps in Jordan (population: 37,932 and 79,034, respectively) and evaluates changes in routine health services during the COVID-19 pandemic. Methods and findings We calculate the descriptive statistics of COVID-19 cases in the United Nations High Commissioner for Refugees (UNHCR)’s linelist and adjusted odds ratios (aORs) for selected outcomes. We evaluate the changes in health services using monthly routine data from UNHCR’s health information system (HIS; January 2018 to March 2021) and apply interrupted time series analysis with a generalized additive model and negative binomial (NB) distribution, accounting for long-term trends and seasonality, reporting results as incidence rate ratios (IRRs). COVID-19 cases were first reported on September 8 and September 13, 2020 in Azraq and Zaatari camps, respectively, 6 months after the first case in Jordan. Incidence rates (IRs) were lower in camps than neighboring governorates (by 37.6% in Azraq (IRR: 0.624, 95% confidence interval [CI]: [0.584 to 0.666], p-value: <0.001) and 40.2% in Zaatari (IRR: 0.598, 95% CI: [0.570, 0.629], p-value: <0.001)) and lower than Jordan (by 59.7% in Azraq (IRR: 0.403, 95% CI: [0.378 to 0.430], p-value: <0.001) and by 63.3% in Zaatari (IRR: 0.367, 95% CI: [0.350 to 0.385], p-value: <0.001)). Characteristics of cases and risk factors for negative disease outcomes were consistent with increasing COVID-19 evidence. The following health services reported an immediate decline during the first year of COVID-19: healthcare utilization (by 32% in Azraq (IRR: 0.680, 95% CI [0.549 to 0.843], p-value < 0.001) and by 24.2% in Zaatari (IRR: 0.758, 95% CI [0.577 to 0.995], p-value = 0.046)); consultations for respiratory tract infections (RTIs; by 25.1% in Azraq (IRR: 0.749, 95% CI: [0.596 to 0.940], p-value = 0.013 and by 37.5% in Zaatari (IRR: 0.625, 95% CI: [0.461 to 0.849], p-value = 0.003)); and family planning (new and repeat family planning consultations decreased by 47.4% in Azraq (IRR: 0.526, 95% CI: [0.376 to 0.736], p-value = <0.001) and 47.6% in Zaatari (IRR: 0.524, 95% CI: [0.312 to 0.878], p-value = 0.014)). Maternal and child health services as well as noncommunicable diseases did not show major changes compared to pre–COVID-19 period. Conducting interrupted time series analyses in volatile settings such refugee camps can be challenging as it may be difficult to meet some analytical assumptions and to mitigate threats to validity. The main limitation of this study relates therefore to possible unmeasured confounding. Conclusions COVID-19 transmission was lower in camps than outside of camps. Refugees may have been affected from external transmission, rather than driving it. Various types of health services were affected differently, but disruptions appear to have been limited in the 2 camps compared to other noncamp settings. These insights into Jordan’s refugee camps during the first year of the COVID-19 pandemic set the stage for follow-up research to investigate how infection susceptibility evolved over time, as well as which mitigation strategies were more successful and accepted.

The first year of the COVID-19 pandemic in humanitarian settings: epidemiology, health service utilization, and health care seeking behavior in Bangui and surrounding areas, Central African Republic

“…The reduction in consultations for RTIs has been observed in several countries, including Vietnam, Uganda, Kenya, Zambia, and China [ 46 – 50 ] and refugee settings in Jordan and Uganda [ 51 , 52 ]. It was likely due to a variety of reasons, including changes in health-seeking behaviors due to difficulty in reaching health facilities, fear of being infected or of being tested, as well as an effective reduction in common RTIs due to COVID-19 related preventative measures such as masks, physical distancing, and school closures.…”

Development of a Prediction Model for the Management of Noncommunicable Diseases Among Older Syrian Refugees Amidst the COVID-19 Pandemic in Lebanon

“…16 However, the COVID-19 pandemic and the recent major economic crisis in Lebanon have impacted access to health care and supply of essential medications, 17,18 which may have a negative impact on the health status of Syrian refugees. 19,20 Studies on NCD management among refugees in Lebanon and the Middle East, a region that hosts one of the largest refugee populations, are scarce. 12 Understanding the barriers and predictors of self-reported management of NCDs among older refugees, a population at high risk for severe COVID-19 outcomes, is important to allow resource allocation and contextualized humanitarian assistance to prevent premature mortality and morbidity.…”

“…Syrian refugees have free access to chronic disease medication through the United Nations High Commissioner for Refugees (UNHCR) or other nongovernmental organizations . However, the COVID-19 pandemic and the recent major economic crisis in Lebanon have impacted access to health care and supply of essential medications, which may have a negative impact on the health status of Syrian refugees …”

Addressing the impacts of COVID-19 on refugee health

“…In an accompanying study in PLOS Medicine , Altare and colleagues report results from a retrospective cohort study of COVID-19 epidemiology and heathcare services utilization in Azraq and Zaatari refugee camps in Jordan [ 3 ]. More than 5.5 million Syrians have fled the country since the Syrian Civil War broke out in 2011, with most settling in neighboring countries [ 4 ].…”

“…As of September 2020, Jordan had reported around 2,500 COVID-19 cases and 17 deaths. Using a surveillance line list and monthly routine data from UNHCR’s health information system from the 2 camps, Altare and colleagues calculated descriptive statistics of COVID-19 cases and adjusted odds ratios for selected outcomes [ 3 ]. These outcomes included COVID-19 confirmation, health service utilization for infectious disease, noncommunicable disease, and maternal and child health.…”